Evidence-based practice should be included in occupational therapy curricula (1, 12), to support students’ utilization of EBP in their clinical practice. The results indicated that the occupational therapy students regarded EBP as important for clinical practice, but they experienced problems in applying EBP. Providing students with training in using the EBP work file was not enough to strengthen their self-perceived ability to apply EBP to clinical practice.
The average scores in other comparable studies of the EBP Belief Scale vary from 53.0 to 64.1 (maximum 80) (19), which is similar to our results. Our results indicate that bachelor level students of occupational therapy believe that EBP results in the best clinical care for patients, although they thought EBP was too time consuming and perceived it as difficult to apply. Similar barriers have been found in previous research (5-9). The EBP work file is designed to help and assist students in every step of the EBP process (16), although it does not facilitate student’s application of EBP in clinical situations. To support the student’s application of EBP in clinical placement, the students probably need a more concrete and relevant EBP assignment related to real world problems. This aligns with previous research which emphasizes that EBP teaching should be meaningful and of relevance to the students (1).
EBP teaching for occupational therapy students at OsloMet and HVL seems to concentrate on the first steps of EBP, e.g. searching for, finding and critically appraising evidence, with less emphasis on integrating and using research evidence in conjunction with clinical and user experiences. The use and translation of research evidence into clinical practice needs to be prioritized (11, 13), including enabling students to apply all the steps of the EBP process (3). More emphasis on the last step of the EBP process, namely integrating and using research evidence, could boost student’s motivation, enabling them to understand and acknowledge that EBP makes a difference in relation to best practice.
Previous research indicates that students have trouble retaining and using EBP skills beyond the classroom (9, 10). Thus, the students may have perceived the EBP work file as a university assignment, unrelated to clinical practice. When assignments are regarded as separate from clinical practice, the translation of EBP is not assured (11). Teaching strategies, such as using relevant, authentic cases which include the natural complexities of the world, seem important (11). Crabtree et al. (10) suggested using practice scenarios facilitated by clinical instructors, to make the teaching more relevant and realistic for the students. These suggestions may contribute to closing the gap between theoretical and practical knowledge, although this may not guarantee that EBP is integrated into a student’s clinical work. An online tracking of the student’s EBP work could potentially enable faculty and clinical instructors to support students in the application of EBP during clinical placement.
EBP implementation was low in terms of the occupational therapy students, although our results are slightly higher than those reported in a study by Stokke et al. (20), in which Norwegian nurses recorded an average score of 7.8 (compared to 15.4 in the present study). The lack of utilization of EBP on the part of occupational therapists’ may also be found in a systematic review of occupational therapists’ implementation of EBP (23). This indicates that the implementation of EBP may be challenging for healthcare professionals, including occupational therapists, and consequently, they have difficulty acting as EBP role models for students. Several studies have reported on the lack of support from clinical instructors, amongst others, as a barrier to EBP, affecting students in their clinical placements (6, 9, 10, 24). Considering that the implementation process, in general, is demanding for healthcare professionals, it is, therefore, not surprising that occupational therapy students have difficulty in applying EBP. Supporting clinical instructors to be confident in terms of their own competence when teaching EBP and to present themselves as role models for students, can assist students in applying EBP during clinical placements (1).
The translation of evidence and implementation of EBP in clinical placements is influenced by several factors, such as the access to research evidence, deciding on the applicability of the evidence and the need for habits to change (12). The accessibility of research evidence has been highlighted as a significant barrier for occupational therapists’ (23). Students have easy access to a variety of research evidence via the university library, which could benefit the clinical instructors. Having access to the research evidence, the students and clinical instructors could read and discuss this evidence and decide whether to include the results from research in practice, e.g., conducting a journal club. Journal clubs may serve to support the implementation of EBP (11, 12, 23).
Teaching and learning EBP form just one element of the training of occupational therapy students during clinical placements. Competing demands and other priorities have been found to act as a barrier to applying EBP during clinical placements (5). In this study, the EBP work file, provided as an assignment was insufficient to enable occupational therapy students to increase the implementation of EBP during clinical placements. EBP assignments probably need to be introduced and worked on during clinical placements, with clinical instructors actively involved (5) in supporting the students, to translate the research evidence into practice (11).
Implications for occupational therapy education
We argue that including an EBP-based assignment during clinical placements is insufficient in terms of boosting students’ confidence in engaging with EBP. EBP teaching and its associated assignments should include the active involvement of both students and clinical instructors. Had the EBP work file been better integrated as part of the clinical placement and been known to the clinical instructors, the outcome in relation to the students’ self-perceived attitudes and behaviours towards applying EBP to clinical placements, may have been better. Previous research has noted the importance of including clinical instructors in the planning and delivery of EBP curricula activities during clinical placements (10). For example, the faculty should involve and collaborate with clinical instructors with a view to giving students opportunities to present and discuss the results of research articles and to implement EBP in clinical placements. One recommendation to overcoming EBP barriers, is to include a structural incorporation of EBP in clinical placements (1). Involving clinical instructors in the inclusion of EBP in clinical placements, may contribute to closing the gap between theoretical teaching and practice, enabling students to translate research evidence into practice and potentially effect practice change (11). Clinical placement provides a unique opportunity of learning the implementation of EBP in patient treatment and can promote motivation for lifelong learning.
Study strengths and limitations
Participants in this study included bachelor students from two different occupational therapy programmes in Norway from three different year groups, providing a wider cross-section of students’ self-reported attitudes and behaviour towards EBP. However, the fact that only two study sites in one country were used, render the sample small, therefore, the results should be treated with caution. The study’s limitations include a limited sample size and the lack of a control group. This may have led to differences in the results according to the confounding variables. However, the use of ANOVA with Bonferroni correction has controlled for confounding variables.
The authors have considered whether the questionnaires may have been difficult to answer due to the role of students in clinical placements, especially questions related to implementation of EBP, for example, “[I have] [u]sed evidence to change my clinical practice”. A barrier to employing an evidence-based method is insufficient autonomy to be able to change practice (8). Bachelor level students of occupational therapy would not be expected to change the practice of the institution while on placement, but they could be engaged in the process of change in consultation with their clinical instructor. Therefore, the question could potentially be changed to “I have used evidence and changed practice together with my clinical instructor”, which might be more appropriate for students.
The translation of both questionnaires into the Norwegian language was carried out in accordance with the WHO’s process of translation and adaptation of instruments (19). However, the questionnaires have not been tested for cross-cultural validity, which may be a potential limitation in this study. Future research could use control groups and interviews with both students and clinical instructors to investigate further how best to implement EBP teaching strategies during clinical placements. An online tracking of the EBP work file could also reinforce the results of the study.